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Impacts of electronic health records on patients
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INTRODUCTION
As technology advances so must our way of accessing information. Many medical facilities and health care professionals are switching from paper medical records to Electronic Medical and Health Records. Incorporating information technology into the health field through electronic records can enhance the quality of care by making patient data more accessible to all healthcare providers and eliminating medical errors.
BACKGROUND
Electronic Medical Records and Electronic Health Records may seem the same but they do have some differences. According to National Alliance for Health Information Technology EMR (Electronic Medical Records) are the “electronic record of health information of health-related information on an individual that
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Do to the many threats to information technology, Electronic Medical Records are at risk of malice attacks, hackers, unintentional insider disclosure, insider abuse and unauthorized access. Security breaches pose a threat to patient privacy especially when confidential health information is made available to others without authorization and consent.
There are several different ethical codes that must be followed by all authorized users to help ensure that PII is protected. The Association of Computer Machinery has a code of Ethics that breaks down the need, the provisions, the restrictions, the time and place of access to patients information, which they believe will detour the misuse of data and cause a respect for others privacy (Conners & Mick, 1997). However, using technology can protect technology, implementing security measures like firewalls, antivirus and intrusion detection software can protect the integrity of data. Performing routine audits can ensure compliance with healthcare policies and encrypting information can aide in protecting patients PII from unauthorized
As the evolution of healthcare from paper documentation to electronic documentation and ordering, the security of patient information is becoming more difficult to maintain. Electronic healthcare records (EHR), telenursing, Computer Physician Order Entry (CPOE) are a major part of the future of medicine. Social media also plays a role in the security of patient formation. Compromising data in the information age is as easy as pressing a send button. New technology presents new challenges to maintaining patient privacy. The topic for this annotated bibliography is the Health Insurance Portability and Accountability Act (HIPAA). Nursing informatics role is imperative to assist in the creation and maintenance of the ease of the programs and maintain regulations compliant to HIPAA. As a nurse, most documentation and order entry is done electronically and is important to understand the core concepts of HIPAA regarding electronic healthcare records. Using keywords HIPAA and informatics, the author chose these resources from scholarly journals, peer reviewed articles, and print based articles and text books. These sources provide how and when to share patient information, guidelines and regulation d of HIPAA, and the implementation in relation to electronic future of nursing.
For years now, the healthcare system in the United States have managed patient’s health records through paper charting, this has since changed for the better with the introduction of an electronic medical record (EMR) system. This type of system has helped healthcare providers, hospitals and other ambulatory institutions extract data from a patient’s chart to help expedite clinical diagnosis and providing necessary care. Although this form of technology shows great promise, studies have shown that this system is just a foundation to the next evolution of health technology. The transformation of EMR to electronic heath record system (EHR) is the ultimate goal of the federal government.
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
Medical Center data is extremely important to keep very secure. Hackers may have the ability to alter treatments to be initiated to paitients if they are able to alter documents: paitients must be informed therefore and agree with all treatment protocols to be initiated. If patients are correctly informed about their treatments they can be given the ability to remember and know when things have changed. Uninformed patients may not even know the details of their treatments, this cannot happen. Don't assume that hackers will not try to do things of this nature if they can. In addition people may hire hackers to do certain things: medical centers cannot rely on their electronic systems alone, because if they do..
Security problems generally involve a leak of information because of the type of technology being used in clinical and online practice, such as computers, mobile devices (e.g., cell phones or tablets), email, voicemail, fax machines, electronic records on large servers, and the Internet when administering psychological services online. Regrettably, protection of confidentiality has yet to catch up with the majority of these technological advancements. Some of the primary threats to the security of confidentially information originates from things like web or email viruses, online hackers looking to access information, flaws in software or firewalls, damage or malfunction to the technology itself, and user error (Regueiro et al.,
This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
Over the years, healthcare facilities have acted like a storehouse for patients’ medical records, uninterested and unable to distribute clinical data to anyone beyond their organization. The EHR, started in the 1960s under the name of "computerized-based patient record" (CPR), became known as "electronic medical records" (EMR) in the 1990s and today it is known as electronic health record (EHR).The target of the Department of Health and Human Services (HHS) is to incorporate the EHR and use it in a "meaningful" way to improve the quality, efficiency, and safety of patient care delivery; to engage patients in their personal health record; and to improve care coordination. Equally important, the "meaningful use" of the EHR system intends to build a bridge to other systems by creating an interoperability of health information while implementing quality care throughout. However, this interoperability can only be accomplished when the receiving system and the user fully understand how to apply these exchanges.
The EHR is a computerized health record that will take place of the paper chart. The health care information will be available to all health care providers at anytime, anywhere. The record will contain medical history, diagnosis, medications, immunization, allergies, diagnostics and lab results; from past doctors, emergency department visits, school, pharmacies, and out patient laboratories and facilities (Department of health and human services, 2014). Health care providers will be able to access evidence-based tools to aid in decision-making. EHR will also streamline workflow, and support changes in payer requirements and consumer expectations. In 2004, “the HHS secretary, Tommy Thompson appointed David Brailer as the national health information coordinator to provide: leadership for the development and nationwide implementation of a interoperable HIT infrastructure, with the goal of establishing electronic health records...
We as nurses rely on technology, but we also have been taught to beware technology from making judgments for our nursing car. We know that technology can be wrong or mess up just like a human; therefore, we must always be knowledgeable and question our practice, to ensure safe nursing. Technology has pros and cons just like the human person does. “Storing clinical data, translating clinical data into information, linking clinical data and domain knowledge, and aggregating clinical data” is a helpful and time saving use of technology (Yoder-Wise, 2015). However, technology sometimes take precious time away; for example, a study found that “nurses spend up to 40% of their workday meeting ever-increasing demands from the systems in which they work” (Yoder-Wise, 2015). Technology also brings up an “ethical dilemma” as to when and how to use “extraordinary means to prolong life for patients with limited or no decision making capabilities” (Yoder-Wise, 2015). When is technology prolonging pain and hindering a peaceful natural death. Other issues like, “safeguarding patient’s welfare, privacy, and confidentiality” have been called into question with use of patient information in the computer systems (Yoder-Wise, 2015). There has to be safety parameter to protect patients according to HIPPA law, for example firewalls (Yoder-Wise, 2015). However, computerized patient information has also been a live saver and time saver because “provider order entry” is more clearly written,
Electronic health records is medical information recorded on computers, the data consists of a variety of data, medical history, medication, allergies, diagnoses, immunizations, labs, radiology, vital signs, billing information, and personal statistics weight and age. The EHR is designed to help with medical errors. It helps reduce errors with allergies to a medication. Also help with reading legibility and eliminate the lost forms and paperwork. It allows for the patients history to be viewed by several doctors. Doctors or nurses can update information on your record.
The purpose of this paper is to discuss how Electronic Medical Records (EMR), affects healthcare delivery. I will discuss the positives and negatives this issue has on healthcare and how it effects the cost and quality for healthcare services. In addition, I will identify any potential trade-offs to cost or quality. Lastly, I will discuss how the EMR affects my job as well as any challenges or opportunities this issue presents.
Health information opponents has question the delivery and handling of patients electronic health records by health care organization and workers. The laws and regulations that set the framework protecting a user’s health information has become a major factor in how information is used and disclosed. The ability to share a patient document using Electronic Health Records (EHRs) is a critical component in the United States effort to show transparency and quality of healthcare records while protecting patient privacy. In 1996, under President Clinton administration, the US “Department of Health and Human Services (DHHS)” established national standards for the safeguard of certain health information. As a result, the Health Insurance Portability and Accountability Act of 1996 or (HIPAA) was established. HIPAA security standards required healthcare providers to ensure confidentiality and integrity of individual health information. This also included insurance administration and insurance portability. According to Health Information Portability and Accountability Act (HIPAA), an organization must guarantee the integrity, confidentiality, and security of sensitive patient data (Heckle & Lutters, 2011).
Our clinical knowledge is expanding. The researcher has first proposed the concept of electronic health record (EHR) to gather and analyze every clinical outcome. By late 1990s computer-based patient record (CPR) replaced with the term EHR (Wager et al., 2009). The process of implementing EHR occurs over a number of years. An electronic record of health-related information on individual conforms interoperability standards can create, manage and consult with the authorized health professionals (Wager et al., 2009). This information technology system electronically gather and store patient data, and supply that information as needed to the healthcare professionals, as well as a caregiver can also access, edit or input new information; this system function as a decision support tools to the health professionals. Every healthcare organization is increasingly aware of the importance of adopting EHR to improve the patient satisfaction, safety, and lowering the medical costs.
Ragavan, V. (2012, August 27). Medical Records Pals Malaysia : 17 Posibble Reasons How Electronic Medical Records (EMR) Might Support Day-to-Day Patient Care. Retrieved from Medical Records Pals Malaysia: http://mrpalsmy.wordpress.com/category/emr/